Provider Demographics
NPI:1902271703
Name:PALENCIA, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:PALENCIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 CHANDON
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-5727
Mailing Address - Country:US
Mailing Address - Phone:708-217-7405
Mailing Address - Fax:
Practice Address - Street 1:16536 MANCHESTER ST
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477
Practice Address - Country:US
Practice Address - Phone:708-217-7405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-04
Last Update Date:2018-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program